Infections with Nonthoracotomy Implantable Cardioverter Defibrillators: Can These Be Prevented?

Abstract

Nonthoracotomy ICDs are believed to be the best therapeutic modality for treatment of life-threatening ventricular arrhythmias. Little is known about the risk of infection with initial implantation of these devices. We studied the incidence, clinical characteristics, and risk factors associated with infections in 1,831 patients with nonthoracotomy ICD from the Endotak-C nonthoracotomy lead registry of Cardiac Pacemakers, Inc. A transvenous lead was implanted in 950 patients (51.9%) and a combination transvenous plus subcutaneous patch was used in 881 patients (48.1%). Nine preselected data variables were studied, and all investigators identified as having patients with infections were personally contacted. Infections occurred in 22 (1.2%) of 1,831 patients receiving this nonthoracotomy ICD system. The mean time to infection was 5.7 +/- 6.5 months (range 1-25 months). Staphylococci were isolated in 58% of patients with reported infection. The presence of a subcutaneous defibrillator patch system was associated with the development of infection. Six of 950 patients (0.63%) with a totally transvenous lead system developed infection versus 16 of 838 (1.9%) patients with a transvenous lead plus subcutaneous patch system configuration (P = 0.015, Chi-square test), with an unadjusted estimated odds ratio of 3.06 (CI 1.19-7.86). The risk of infection encountered with the nonthoracotomy ICD is low, estimated from our data to be 1.2%. Placement of a subcutaneous defibrillator patch appears to be an independent risk factor for development of infection.

Staphylococcus aureus Bacteremia in Patients With Permanent Pacemakers or Implantable Cardioverter-Defibrillators

“…Previous studies have shown that CDI occurs in 0.13% to 19.9% of permanent pacemakers 2,3,5,8,11 and 0.8% to 1.3% of transvenous non-thoracotomy implantable cardioverter-defibrillators. 7,17,26 The most relevant clinical question, however, is not the overall incidence of CDI among patients with these devices but rather the incidence of CDI in patients who present with SAB. The present study answers this question with several key observations.…”

“…Although Staphylococcus aureus is an important cause of CDI, 4,7,10,[12][13][14][15][16][17][18] the risk of developing CDI after S aureus bacteremia (SAB) is inadequately defined. This uncertainty complicates patient management.…”

Implantable cardioverter defibrillator pocket infection caused by Stenotrophomonas maltophilia

“…ICD pocket infections are rare. The overall incidence of infections ranged from 0.5-2.2% of patients in a review [10]. Several risk factors for ICD infection have been reports among them, male sex, lack of antimicrobial prophylaxis during the implantation procedure, the number of prior cardiac implantation procedures, and type of device [11].…”

Device Infections

“…6 Various observational studies suggest that device infection rates range from 1% to 7%. [7][8][9][10][11] In general, implantable cardioverter-defibrillators have a higher rate of infection compared with pacemakers. 12 Factors that increase the risk of device infection include diabetes mellitus, previous glucocorticoid therapy, underlying malignancy, operator inexperience, multiple lead placement, advanced patient age, oral anticoagulant use, 13 frequent generator replacement, heart failure, fever before device implantation, 14 use of temporary pacing catheters, 14 nonpectoral (abdominal or thoracoscopic) implantations, 15,16 and renal dysfunction.…”

“…8,[25][26][27][28] CIED infection within 2 weeks of pocket manipulation is most commonly attributable to S aureus infection. 29,30 Streptococci, propionibacterium species, corynebacterium species, Gramnegative bacilli, nontuberculous mycobacteria, aspergillus, coxiella species, and candida can occasionally cause CIED infections.…”